Monday, March 06, 2017

Do we have to repeal the ACA to find out what's in it?

No one is claiming that the ACA led us into health access paradise. The ACA marketplace and wider individual market as open enrollment for 2017 began. But they were (and are) troubled markets, in need of adjustment, e.g. along lines sketched by scholars at Georgetown and the Urban Institute. The networks keep narrowing, premiums and out-of-pocket costs have spiked, and choice has narrowed in many markets. The roughly half of marketplace enrollees with strong Cost Sharing Reduction subsidies are partly but not wholly insulated from this deterioration.  Those who are unsubsidized or lightly subsidized have in many cases been hit hard.

The Medicaid expansion has been a clear boon to those who gained access through it, as well as to state budgets, state economies, state public health, and access to drug treatment. It's also, to some extent, highlighted the law's political weakness, apparently triggering a fair amount of Medicaid envy and resentment among the somewhat more affluent and the fact that the ACA's most direct beneficiaries are generally the poor and near-poor.

As mentioned in a prior post, I have a piece shopping that spotlights very mixed experiences of unsubsidized marketplace enrollees with pre-existing conditions -- grateful for access but dealing with rising costs.

Another piece relaying a wide variety of experience and perception, by Jay Hancock of Kaiser Health News, is a striking contrast to the polarized praise/denunciations that used to be common fare in ACA coverage. There is a really striking degree of nuance in these mostly Republican reflections, as well as a refreshing awareness in some cases of the ACA's different component parts. If nothing else, the rough number of people who have gained insurance through the law seems finally to have been hammered home. I hope Hancock doesn't mind my extracting all of the article's citizen testimony, as I do think it has a strong cumulative effect:

“At first it was a good deal — that was three or four years ago,” said Mark Bunkosky, 56, an independent contractor in Michigan who buys coverage through one of the law’s online portals. “Every year it’s gone up. From where it started, the premium has doubled, and now my deductible has also doubled. And my income has not doubled.”

Bunkosky, a Republican, views the ACA unfavorably but believes Washington should fix it, not toss it. He supports keeping some of the law’s Medicaid coverage for low-income people and its prohibition on discriminating against those with preexisting illness....

... Bunkosky, a contractor for heating and air conditioning, urged Republicans to think hard about any Obamacare replacement.

“Everybody’s in a hurry for it, but they need to sit down and do it right,” he said. “Some of it is still a good idea. You shouldn’t have to worry about preexisting conditions.”


“I didn’t like that it mandated people to carry health insurance. And I thought it was just a lie” when it promised affordability, said Amber Alexander, 27, a Pennsylvania independent whose seasonal income puts her on Medicaid in winter and a commercial plan the rest of the year.

However, she said, “I don’t think it should be thrown out altogether. There are people that do benefit from it, but there are also a lot of people that get screwed.”


Carol Friendly, 67, is an Oregon Republican who voted for Hillary Clinton for president and favors the health law’s Medicaid expansion, which many Republican policymakers excoriated but has gained support among some GOP governors. She objects to the ACA’s reproductive health coverage, saying consumers opposed to birth control and abortion shouldn’t have to pay for them.

On the other hand, “I know it put 22 million in the health care system that weren’t there before,” she said. “So that’s a plus.”


My story thus far has been one who has benefited from the system,” said Michael Bilodeau, 39, who attended two town halls by California Republican Rep. Tom McClintock. “We are able to see our local doctor, who we like. And our premiums have been, I would say, stable.”

He co-owns a small business with his wife and is on a plan from Covered California, the state’s online marketplace.

“One of the Republicans’ major arguments is that the ACA brought disruption to people’s health care,” Bilodeau said. “It feels like we’re headed toward another disruption.”

Some Republican voters object to the ACA not because it expanded coverage but because it did so in such a complex way, with sliding subsidies and reliance on private insurers selling expensive plans with narrow doctor networks.

“It would have been better if the federal government had said, look, to get these 20 million insured let’s just expand Medicaid nationwide and let’s leave everybody else alone,” said Rickey Mathis, 56, a Georgian who voted for Trump and hasn’t had insurance since the factory employing him closed in 2012. “Why did they have to screw up the whole country’s health insurance?”
No, the ACA didn't "screw up the whole country's health insurance" -- it didn't much affect most people's.   It did make some number of people -- in the single digit millions -- pay more than they would have for health insurance in the individual market, while enabling perhaps twice as many to pay less in that market or to gain access they wouldn't have had pre-ACA.  OTH, I don't think "let's just expand Medicaid" is an invalid take -- in fact, I'd extend it to "let's make the whole individual market more like (managed) Medicaid."

If Americans' views have grown more nuanced as the law comes under mortal threat, so has that of some Republican lawmakers, particularly those in states that expanded Medicaid. The New York Times's Jennifer Steinhauer gives the final word on this front to the most conservative Democratic senator, Joe Manchin of West Virginia -- a state that's slashed its uninsurance rate by 58% under the ACA, mainly via the Medicaid expansion:
As residents become aware that benefits they have received were part of the health law and may go away, so do their elected representatives.

“In some ways it has been a health care education process for everyone,” Mr. Manchin said. “Even for people here.”
How sad it would be if it turns out we had to repeal the ACA to find out what's in it.

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